This government response is a welcomed government response, and one that is much more timely than others in the past. The report itself raises some very important questions, and in some ways I appreciate having, in this response from government, a fairly clear description of what I think is a major area of difficulty. One of the things our report found was that Australia was a country with one of the highest caesarean section rates in the world, and that if you were privately insured you were much more likely to have a caesarean section than if you were a patient in the public sector. Evidence provided to the committee showed there was no clear reason why that should be the case.

I received a report today, Thursday 31 August—I think it is probably off my email—which said that, in the United States, after years of decline, caesarean sections are on the rise again. The evidence in the report from America is extremely similar to what we found in our report: that there is a very big difference between caesarean section rates across the country and that there is a much higher likelihood of caesarean sections for women if they are privately insured than if they are public patients. That seems to me to be, first of all, worthy of very serious investigation and follow-up. The government's response says:

Most of the views and recommendations of the Report however, are in the realm of State and Territory Government responsibilities or comment upon clinical decisions. The Government does not consider that this form of inquiry—

presumably a Senate inquiry—

is best suited to assess quality, safety and relevance in clinical matters.

It says four paragraphs later:

Government Approaches to Improving Australia's Health System

The Government is funding and driving programs of health system improvement on a scale greater than has been seen in Australia before. Criteria of quality, safety, relevance, choice, equity of access and effectiveness based on evidence are paramount. This Response to the Report outlines some relevant initiatives.

My first-up confusion about this is that paragraph 1 says that quality, safety and relevance are judged as clinical matters and outside the purview of a Senate inquiry, while paragraph 5 says that quality, safety, relevance, choice, access and effectiveness are criteria for the federal government's health policy. If we do not want to have a brawl, could I please have some further clarification? If, as the government say, they are concerned that quality, safety, relevance and choice, for example, are criteria by which you would judge an Australian health system but not this report because some of those applied to clinical matters, then I am nothing if not confused about what is the government's response in this area.

I am particularly concerned when they say that a lot of our recommendations go to things like how services are delivered in the states, but the states' way of delivering the services is outside the responsibility of the federal government. However, the federal government provide, through broad public health outcome funding agreements—PHOFAs—funding to state and territory governments and have agreements with them for delivering those services. If a caesarean section rate is not an outcome, what is it? If I seriously wanted to know how to judge in an appropriate way—without intruding on clinical professional decisions and without intruding on states' rights to do things—where Commonwealth dollars allocated to childbirth and delivery go in this country, then the way I measure this is in outcomes. What is the caesarean section rate if it is not an outcome? The caesarean section rate is merely data counting. It would be entirely proper for the federal government to be concerned about an outcome under their public health outcome funding agreements where caesarean section rates are higher in this country than anywhere else in the world and higher by a significant factor for privately insured patients and higher from one state to another.

My own state of South Australia, as I recollect, has the highest figure, or it did in the findings of our report. When we asked if that had anything to do with the state having the highest number of obstetricians, there was some concern that there might be a correlation. We concluded that, as they were the only people who could do caesarean sections, it was a very valid reason to worry. The American data shows just that. In fact, one college in America is concerned that the only differences between caesarean section rates are the practices and the habits of doctors. We were also told of one doctor who went to a large public hospital in South Australia and had set out to significantly lower the caesarean section rate. He was very successful in doing this. There was no increase in infant mortality or maternal damage. There was just a significant lowering of the caesarean section rate in the public hospital and, interestingly, an allied reduction in the caesarean section rate amongst the private practitioners in the environs of that hospital. We also heard that this same pattern happened when a senior obstetrician in Tasmania set out to look at the figures in Tasmania and to work with clinicians to see if that figure could not be lowered. I have been talking about caesarean section rates, but the figures are on the increase for all interventions in childbirth—be they episiotomies, vacuum extractions, the use of forceps, medication, epidurals, anaesthetics and so on.

I thank the government for the response, but I have to remark on the way they have said that a number of our recommendations belong in the state and territory area and that, therefore, the Commonwealth does not want to have much say about them. When the Commonwealth directly funds those programs with precious Commonwealth taxpayer dollars, I would like to know how the Commonwealth is so easily able to say, `We handball that to the states; it is not our responsibility.'

I heard, during question time today, considerable kudos being claimed for itself by the government, for how it has reduced through the immunisation program the number of people who have had measles, mumps, diphtheria and so on. The immunisation program is a classic Commonwealth-state program. It is a service delivered by the states, providing data to the Commonwealth, and it is a very good example—and I think the Commonwealth properly can claim some responsibility for reducing immunisation rates. But it does not do this by saying, `Don't talk to us about those figures; that is a state matter; we do not really have any responsibility for it.' Yes, the Commonwealth does have. It has clear responsibility under its own public health outcomes funding agreements. I want to know what they call `outcomes'. I am also concerned about how I can go to the estimates and find out how our Commonwealth dollars are being spent on health and on obstetric services. To be met by the Commonwealth saying, `Well, it's really a state matter—talk to them,' is not, I believe, a sufficient answer or justification. As I say, it is quite contrary to what they are claiming in the area of immunisation.

There are some other points here that I think are very important. The government clearly recognises the importance of our inquiry and agrees that some of the recommendations we have made should be picked up on, particularly where we have asked whether the NHMRC could pick up and develop the research, and so on. The Commonwealth also says—and this is a concern for me—that it has a very direct responsibility for something like, for example, ultrasound—and indeed this report tells us that in 1998-99 $38.6 million was paid in Medicare benefits in respect of ultrasound. But they then go on to say that a lot of the ultrasound work is done in public hospitals, and that that is a state funding matter and not something that the Commonwealth would concern itself about.

I find that extremely disappointing, because half of the funding to our public hospitals is from the Commonwealth and also because the criterion for reasonable and decent ultrasound has to apply in the public as well as the private sector—and some of that is acknowledged by the Commonwealth in its response to other recommendations. Importantly, continuity of care—which we found so important in reducing caesarean section rates and in having happier mothers and happier babies—is certainly given support by the Commonwealth. The government says in its response that some of its funding is going very much into that kind of area, and so I acknowledge that support for the recommendations we made in that area. I think it was an invaluable report from the Senate. The government's response is largely positive but, as I say, its qualification about some of these matters being state government responsibilities does not hold water and does not assist with outcomes for Australian women.